Private Health Insurance (Complying Product) Amendment Rules 2008 (No. 4) (Cth)

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Private Health Insurance (Complying Product) Amendment Rules 2008 (No. 4)

I, KERRY FLANAGAN, delegate of the Minister for Health and Ageing,make these Rules under item 3 of the table in section 333-20 of the Private Health Insurance Act 2007.

Dated

11th December 2008

Kerry Flanagan

____________________________________

Kerry Flanagan

First Assistant Secretary

Acute Care Division

Department of Health and Ageing

Contents

3. Amendment of the Private Health Insurance (Complying Product) Rules 2008 (No. 2) 3

Schedule ― Amendments4

Part 1Preliminary

1.Name of Rules

These Rules are the Private Health Insurance (Complying Product) Amendment Rules 2008 (No. 4).

2.Commencement

These Rules commence on 1 January 2009, or if registered after that date, on the day after they are registered.

3.Amendment of the Private Health Insurance (Complying Product) Rules 2008 (No. 2)

The Schedule amends the Private Health Insurance (Complying Product) Rules 2008 (No. 2).

Schedule – Amendments

[1] Schedule 2―Standard information statements: general treatment

Delete Schedule 2, substitute:

Schedule 2―Standard information statements: general treatment

Form of statement

Note: The next page of these rules is page 16. It appears without page number, header or footer. This is to allow the form to be shown in its actual size as an A4 page.

Private Health Insurance Standard Information Statement – General Treatment Policy

This Statement provides basic information for the purposes of comparison only. For full explanation of this general treatment policy please contact the health insurer on <phone number> or visit <website URL>.

Health insurer:

<Health Insurer name>

(This insurer has membership restrictions)

Who is covered:

<Type of cover>

Product name:

<Product name>

Monthly premium:

$<xx.yy>(indicative only)

Available for:

Residents of <State/Territory>

Employees/Members of <Company/Organisation name>

Closed to new members

(must be purchased with certain hospital policies)

Medicare Levy Surcharge:

NOT Exempt

Available From:

<dd mmm yyyy>

The monthly premium already has the 30% Rebate deducted and does not include any discounts or higher level of Rebate that may apply.

Preferred service provider arrangements: By using this health insurer’s “preferred providers” you will have lower out-of-pocket costs on <list of services>and have access to more “no gap” services. A list of preferred providers is available from the health insurer. OR Insurer’s own wording

Services

Cover

Waiting period

(Max months)

Benefit limits

(per 12 months)

Examples of maximum benefits

Dental

Periodic oral examination – $<xx.yy> OR

<xx>% of charge

Scale & clean – $ OR % as above

Fluoride treatment – $ OR %

  1. •

    General dental

  1. •

    Major dental

Surgical tooth extraction – $ OR %

Full crown veneered – $ OR %

  1. •

    Endodontic

Filling of one root canal - $ OR %

  1. •

    Orthodontic

Braces for upper & lower teeth, including removal plus fitting of retainer – $ OR %

Optical(eg prescribed spectacles/ contact lenses)

Single vision lenses & frames – $ OR %

Multi-focal lenses & frames – $ OR %

Non PBS pharmaceuticals

Per prescription - $ OR %

Physiotherapy

Initial visit – $ OR %

Subsequent visit – $ OR %

Chiropractic

Initial visit – $ OR %

Subsequent visit – $ OR %

Podiatry

Initial visit – $ OR %

Subsequent visit – $ OR %

Psychology

Initial visit – $ OR %

Subsequent visit – $ OR %

Acupuncture

Initial visit – $ OR %

Subsequent visit – $ OR %

Naturopathy

Initial visit – $ OR %

Subsequent visit – $ OR %

Remedial massage

Initial visit – $ OR %

Subsequent visit – $ OR %

Hearing aids

Per hearing aid – $ OR %

Blood glucose monitors

Per monitor – $ OR %

Ambulance

<Insert appropriate phrase>

¬ <Special features of the product>

Health care programs and other features:

[2] Schedule 3―Standard information statements:

combined products

Delete Schedule 3, substitute:

Schedule 3―Standard information statements:

combined products

Form of statement

Note: The next two pages of these rules are pages 18 and 19. They appear without page numbers, headers or footers. This is to allow the form to be shown in its actual size as two A4 pages.

Private Health Insurance Standard Information Statement – Combined Policy

This Statement provides basic information for the purposes of comparison only. For full explanation of this combined hospital and general treatment policy please contact the health insurer on <phone number> or visit <website URL>.

Health insurer:

<Health Insurer name>

(This insurer has membership restrictions)

Who is covered:

<Type of cover>

Product name:

<Product name>

Monthly premium:

$<xx.yy>(indicative only)

Available for:

Residents of <State/Territory>

Employees/Members of <Company/Organisation name>

Closed to new members

Medicare Levy Surcharge:

<NOT> Exempt

Available From:

<dd mmm yyyy>

The price shown is monthly premium with the 30% Rebate deducted. It does not include any Lifetime Health Cover loading or factor in any discounts that may be available or higher level of Rebate that may apply.

Hospital Component

The following applies to the hospital component for the <Product name> policy from <Health Insurer name>.

What’s covered if i have to go to hospital?

 ü

<Insert appropriate text>

What medical services are not covered at all?

(Exclusions)

 û

<Insert list of exclusions> OR No exclusions

What medical services are only covered to a limited extent?

(Restrictions, Benefit Limitation Periods)

You are not fully covered for: OR No restrictions

•

<Insert list of restrictions>

You are not fully covered for the time period listed after the services for:

OR No benefit limitation periods

•

<Insert list of BLP items + limitation periods>

How long are the waiting periods for new and upgrading members?

 •

<Insert list of waiting periods>

Will i have to pay anything if i go to hospital?

(Excesses, Co-payments, Medical/Hospital gaps)

Excess: <insert appropriate phrase> OR No excess

Extra costs per day (co-payments): <Insert appropriate phrase(s)> OR No co-payments

Doctors’ and hospital bills: <X> out of 10 medical services paid for by this health insurer in <State/Territory> have no out-of-pocket expenses. plus (optionally) This insurer also has arrangements that may mean lower out-of-pocket expenses on doctors’ bills. OR Gap cover benefits are not available under this policy.

You may have to pay additional costs depending on

the doctors chosen

the treatment you are having and

the hospital you go to.

Before you go to hospital, you should ask your doctor, hospital and health insurer about any out-of-pocket costs that may apply to you.

What other features does this hospital policy have?

General Treatment Component

The following applies to the general treatment component for the <Product name> policy from <Health Insurer name>.

Preferred service provider arrangements: By using this health insurer’s “preferred providers” you will have lower out of pocket costs on <list of services> and have access to more “no gap” services. A list of preferred providers is available from the health insurer. OR Insurer’s own wording

Services

Cover

Waiting period

(Max months)

Benefit limits

(per 12 months)

Examples of maximum benefits

Dental

Periodic oral examination – $<xx.yy> OR

xx% of charge

Scale & clean – $ OR % as above

Fluoride treatment – $ OR %

  1. •

    General dental

  1. •

    Major dental

Surgical tooth extraction – $ OR %

Full crown veneered – $ OR %

  1. •

    Endodontic

Filling of one root canal -- $ OR %

  1. •

    Orthodontic

Braces for upper & lower teeth, including removal plus fitting of retainer – $ OR %

Optical (eg prescribed spectacles/ contact lenses)

Single vision lenses & frames – $ OR %

Multi-focal lenses & frames – $ OR %

Non PBS pharmaceuticals

Per prescription – $ OR %

Physiotherapy

Initial visit – $ OR %

Subsequent visit – $ OR %

Chiropractic

Initial visit – $ OR %

Subsequent visit – $ OR %

Podiatry

Initial visit – $ OR %

Subsequent visit – $ OR %

Psychology

Initial visit – $ OR %

Subsequent visit – $ OR %

Acupuncture

Initial visit – $ OR %

Subsequent visit – $ OR %

Naturopathy

Initial visit – $ OR %

Subsequent visit – $ OR %

Remedial massage

Initial visit – $ OR %

Subsequent visit – $ OR %

Hearing aids

Per hearing aid – $ OR %

Blood glucose monitors

Per monitor – $ OR %

Ambulance

<Insert appropriate phrase>

¬ <Special features of the product>

Health care programs and other features:

[3] Schedule 4―Standard information statements: permitted content, Part 3―general treatment

Delete Schedule 4, Part 3, substitute:

Part 3―general treatment

Field

Description

Permitted content

[If available with hospital policy only]:

The statement is to be placed below the premium on the general treatment SIS if the policy cannot be purchased on its own.

Not required for a combined policy.

(must be purchased with a hospital policy) (where the general treatment policy can be purchased with any hospital policy offered by the insurer)

OR

(must be purchased with certain hospital policies) (where there is a set range of hospital policies the general policy can be combined with)

Preferred Service Provider Arrange-ments:

(box)

Describes special arrangements with particular providers.

Text in this box must not exceed 3 lines, including the line with the heading.

Free text up to 3 lines (including the line with the heading)

OR

By using this health insurer’s “preferred providers” you will have lower out of pocket costs on [ insert services or use many allied health] services and have access to more “no gap” services.A list of “preferred providers” is available from the health insurer.

Insurers that do not have preferred provider arrangements must use this phrase.

This health insurer does not operate a preferred provider scheme.

‘Services’ column:

A list of a number of services covered by general treatment.

As provided in form.

Additions, deletions, modifications or rearrangements not permitted

‘Covered’ column:

Indicates if the service is covered or not.

A service is considered to be covered if a benefit is paid for at least one of the examples in the “examples of maximum benefits” columns.

Ambulance is considered to be covered if the description in the “examples of maximum benefits” column indicates it has comprehensive cover or partial cover.

ü (service is covered)

û (service is not covered)

¬ (see note below)

n/a (for ambulance where it is covered by the state government)

‘Waiting Period (max Months)’ column:

The maximum period of time before a member can claim benefits.

Waiting periods for ambulance can be expressed in days or months.

Choose one of…:

When…

-

the service is not covered

[number]

waiting period in months

None

no waiting period

[x days]

short term waiting period for ambulance cover

‘Benefit Limits (per 12 months)’ column:

Limits on benefits.

If there is a limit on general dental, but not on preventative dental, the “(no limit on preventative dental)” words should be used.

If services with combined limits are in adjacent rows in the table, lines between the boxes can be deleted and the limit and list of combined services only written once.

If a sub limit applies on any of these services, use “Sub-limits apply”.

Combined limits for services in non-adjacent boxes must be written in this field in the first occurrence; thereafter “(Combined limit – see [service])”, inserting the name of the service where the list first occurs.

If benefit limits increase over time for any services, only the lowest payable benefit is to be used.

Any combination of:

  1. •

    $[number] per person

  2. •

    $[number] per service

  3. •

    $[number] per policy

If more than one of the above phrases is used, they are to be linked by the words “up to” eg $X per person up to $Y per service up to $Z per policy.

The following may also be used:

  1. •

    $[number] lifetime limit AND/OR

  2. •

    ([number] appliance(s)/service(s) [delete one] every [number] years (if there is a limit on claims every X years) AND/OR

  3. •

    (combined limit for [list services]) OR

  4. •

    (combined limit – see [service]) AND/OR

  5. •

    Sub-limits apply AND/OR

  6. •

    (no limit on preventative dental) OR

  7. •

    No annual limit OR

  8. •

    - (service is not covered)

For combined limits, choose from services:

  1. •

    general dental

  2. •

    major dental

  3. •

    endodontic

  4. •

    orthodontic

  5. •

    optical

  6. •

    non PBS pharmaceuticals

  7. •

    physiotherapy

  8. •

    chiropractic

  9. •

    podiatry

  10. •

    psychology

  11. •

    acupuncture

  12. •

    naturopathy

  13. •

    remedial massage

  14. •

    hearing aids

  15. •

    blood glucose monitors

  16. •

    ambulance

  17. •

    other services

‘Examples of Maximum Benefits’ column:

Examples of the maximum benefit paid for the listed treatments when an insured person visits a practitioner who is not a ‘preferred service provider’.

Only the examples listed may be used.

A percentage figure can only be used where the insurer does not have a maximum limit on the particular item, other than an annual limit. If an insurer pays a benefit that is a percentage of the charge up to a specified dollar limit (i.e. a limit for that item, separately specified from the annual limit), then the specified dollar limit must be used.

General dental, major dental and endodontic examples must be listed even if the service is not covered.

Other examples should be deleted if not covered.

The maximum benefit paid on the following dental item numbers are to be used for the listed examples:

Periodic oral examination – 012

Scale & clean – 114

Fluoride treatment – 121

Surgical tooth extraction – 322

Full crown veneered – 615

Filling of one root canal – 417

Braces for upper & lower teeth, including removal plus fitting of retainer – 881

If surgical tooth extraction is covered under general dental instead of major dental, this example can be moved to the general dental box.

Orthodontics – if different benefits are offered for treatments provided for orthodontists and general dentists, the maximum benefit for an orthodontist should be used.

Optical – if benefits for frames and lenses are paid separately, add together the maximum benefit for each component.

Initial/subsequent visit examples are for individual sessions.

If there is no maximum benefit for the examples listed, the annual benefit limit figure should be used.

Comprehensive cover can only be used to describe ambulance cover where the product at least covers 100% medically necessary ambulance transport.

Otherwise, ‘partly covered’ should be used.

$[xx.yy number]

amount of maximum benefit

[number]% of charge

where there is no maximum benefit limit on the particular item, other than an annual limit.

n/a

For general dental, major dental and endodontic if not covered

-

Other services if not covered – delete example(s)

Ambulance – one of:

  1. •

    Comprehensive cover (see insurer for details) OR

  2. •

    Partly covered (see insurer for details) OR

  3. •

    See hospital policy information (if part of a combined product in states those where ambulance is covered by the State government) OR

  4. •

    Covered by State government OR

  5. •

    - (not covered)

¬ Special Features:

This space must be used to describe special features of the product where ¬ is used.

Free text up to 4 lines.

Health Care Programs and Other Features: (box)

OPTIONAL – this box may be used to describe (for example):

  1. •

    services covered that are not listed in the first column of the main table

  2. •

    discounts for direct debit, paying in advance etc

  3. •

    preventative health/health management programs

  4. •

    loyalty bonus/incentive schemes

  5. •

    other significant product features

Free text up to 4 lines, including the line with the heading.

Note

1. All legislative instruments and compilations are registered on the Federal Register of Legislative Instruments kept under the Legislative Instruments Act 2003.See

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